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Medication Overuse versus Medication Overuse Headache

In 1988, the International Headache Society (IHS) defined symptoms of headaches into a series of diagnoses. These diagnoses were based on the consensus of headache experts (neurologists) worldwide, not on empirical evidence because there were few studies that systematically studied subjects with headaches. At that time, disabling headaches were considered by many physicians as a psychosomatic or functional disorder.

In the early 1990’s, the FDA’s approval of sumatriptan as a migraine specific medication transformed the field of headache into a scientific endeavor.  Research on the pathophysiology of headache created a neurobiological basis for headaches, redefining the process as a biological process rather than a maladaptive somatic coping mechanism.

In 2004 the IHS revised the diagnostic criteria for headache and for the first time provided diagnostic criteria for chronic migraine (International Classification of Headache Disorders–ICHD-2).  This diagnosis was revised in 2006 as an appendix diagnosis (ICHD-2R), where chronic migraine was defined as 15 or more days of headache per month for greater than three successive months with 8 or more headache days fulfilling criteria for episodic migraine or responding to migraine specific medication.  In addition, there could be no medication overuse because Medication Overuse Headache (MOH) was considered a secondary headache disorder, that is, caused by too much medication.

But the struggle over diagnoses still continues. To a practicing clinician, a person with 15 or more headache days per month has chronic migraine (CM). But to the ICDHD-2R, if a person is using too much medication, this has to be discontinued to see whether the chronic migraine continues without medication overuse and to distinguish it from medication overuse headache (MOH).

But what about the patient suffering from 15 or more headache days per month who has missed days of work or school and important family events due to disability associated with headaches. Do clinicians have a responsibility to help that person become more productive without first withdrawing medication?

Recently, a study found that those with chronic migraine who were using a lot of medication used less medication once onabotulinumtoxinA was administered. In short, this study indicated that indeed migraineurs who over-used medication were doing so to cope with pain. Yet reviewers associated with the ICHD-2R blocked the publication of this article because the subjects were not forced to withdraw from medication prior to enrolling in this study. As a result, the results of this study have not yet been published.

Do you believe that Medication Overuse Headache (MOH) is a different type of headache from Chronic Migraine (CM)?

Do you believe that a person should be withdrawn from all acute medications being overused before a preventive medication/procedure is prescribed to differentiate MOH from CM?

Do you believe that a research article should be published if the findings challenge the reviewer’s beliefs about the diagnosis of a disabling condition?

For more information about the treatment of CM and MOH, visit www.managingmigraine.org

For CME about CM, visit http://www.primaryissues.org